Provider Demographics
NPI:1477874642
Name:SMITH, KATHRYN L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 S PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-3665
Mailing Address - Country:US
Mailing Address - Phone:405-334-5272
Mailing Address - Fax:
Practice Address - Street 1:275 S PERKINS RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-3665
Practice Address - Country:US
Practice Address - Phone:405-334-5272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1477874642Medicaid
MIMI2051114Medicare PIN
MI1477874642Medicaid